Invited Commentary

Abstract

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is the most common cause of myocardial infarction in children, with a mortality rate as high as 90% in infancy. However, 10% to 15% of patients survive to adulthood because of extensive intercoronary collaterals, but without surgical intervention, they remain prone to malignant ventricular arrhythmias and sudden death. Surgical correction is justified as soon as a diagnosis is made, and restoring a two-coronary system is the current practice in infants and children. Management of ALCAPA in adults is controversial, however. Studies have demonstrated that a dual-coronary system is superior to a single-coronary system and does prevent long-term morbidity and mortality. Direct reimplantation may be technically more hazardous in adults due to extensive collateralization, increased coronary artery friability, decreased vessel elasticity for mobilization, and potential for catastrophic bleeding. Left internal mammary–left anterior descending artery bypass with intrapulmonary patch closure of the left coronary ostium is an alternative procedure in this subset of patients. Kottayil and colleagues [1Kottayil B.P. Jayakumar K. Dharan B.S. et al.Anomalous origin of left coronary artery from pulmonary artery in older children and adults: direct aortic implantation.Ann Thorac Surg. 2011; 91: 549-554Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar] have demonstrated excellent results with direct reimplantation of the ALCAPA in older children and adults. Most reports do not recommend any intervention to the mitral valve during the first operation in infants because most with moderate or less regurgitation have been shown to regress. It should be noted that although mitral valve replacement was performed in 40% of their patients and does seem high, older children and adults often demonstrate fixed changes of their mitral valve and subvalvar apparatus with papillary muscle fibrosis and dysfunction. Overall the authors should be commended for their surgical results and contribution to the scarce literature on older children and adults with this disease. Anomalous Origin of Left Coronary Artery From Pulmonary Artery in Older Children and Adults: Direct Aortic ImplantationThe Annals of Thoracic SurgeryVol. 91Issue 2PreviewAnomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) presents rarely in adulthood and is treated by different surgical techniques with varying results. This study was undertaken to evaluate the feasibility of reestablishment of a dual coronary system in older children and adults with emphasis on direct aortic implantation. Full-Text PDF